State, critics disagreeing on impact of mental-health cuts

by Mary K. Reinhart - Sept. 21, 2011 12:00 AMThe Arizona Republic

Thousands of Arizona's most severely mentally ill lost a wide range of treatment and services last year when the state made deep budget cuts. Some of them are getting along, and others have deteriorated. But how they are doing as a whole is uncertain.

To help close a billion-dollar budget gap, state lawmakers and Gov. Jan Brewer eliminated all but generic drugs and crisis services, effective July 2010, for 12,000 people diagnosed with serious mental illnesses who don't qualify for Medicaid.

State health officials say the public mental-health system and the people it serves have weathered the cuts without significant incident, largely because of a beefed-up crisis-response system. People may be on the brink before they get help, officials say, but most appear to be getting it.

But many of those directly affected, and the people who care for them, say the loss of services has caused harm to people, including hundreds who have become incarcerated, hospitalized due to psychotic breakdowns or fallen through the tattered safety net and disappeared.

"This violates every rule of public health care," said Dr. Jason Caplan, a psychiatrist at St. Joseph's Hospital and Medical Center, where emergency-room psychiatric consultations have spiked by 40 percent since last spring.

"It may improve the state's bottom line in the short term," Caplan said. "In the long term, this is going to raise the price of health care for everybody."

A lack of comprehensive data makes it difficult to measure the true impact of the cuts, which saved $50 million in fiscal 2011.

The state does not keep track of how many of the seriously mentally ill who lost services in July 2010 have been homeless, jailed or treated in psychiatric hospitals. Nor do health officials know why thousands of people no longer are accepting any state services and are unaccounted for.

Based on the few items the state tracks, including complaints about services, spending by service providers, mortality and calls to crisis hotlines, state administrators say patients, for the most part, have adapted.

"There has been no concerning trend there," said Dr. Laura Nelson, an assistant director for the Arizona Department of Health Services who oversees the state's behavioral-health system. "The system is not experiencing a crisis as a result of this."

The budget cuts

Last year, Brewer and state lawmakers cut funding for adults diagnosed with serious mental illnesses, such as schizophrenia and bipolar disorder, to help bridge the fiscal 2011 budget deficit.

The decision affected people whose income, often from Social Security disability checks, put them just over the federal poverty level of $10,890 a year and made them ineligible for the Arizona Health Care Cost Containment System, the state's Medicaid program.

As a result, more than 12,000 adults lost state funding for brand-name medication, case management, therapy, housing, transportation, hospitalization and other benefits.

The state forced them to switch to cheaper, generic psychoactive medications, stripped them of the case managers they routinely turned to for guidance, took away their bus passes, ended their counseling sessions and uprooted hundreds from their homes.

This group continues to receive state coverage for psychiatric assessments, monthly medication check-ups and associated laboratory and nursing costs.

Brewer, a longtime advocate for the mentally ill, said at the time that the decision to cut funding for this population was gut-wrenching.

Mental-health experts say it's difficult to overstate the importance of case managers, therapy and other support services for someone with a serious mental illness.

"We have many years of experience that demonstrates quite clearly that if you don't provide that kind of structure, they will simply fall between the cracks," said Dr. Paul S. Appelbaum, a Columbia University psychiatry professor and past president of the American Psychiatric Association.

Putting out fires

State health officials and mental-health providers acknowledge that some people have stopped coming to their assigned health clinics and may not be receiving any treatment.

Lawmakers earmarked an additional $16 million to enhance the state's crisis-response system in hopes of hanging on to as many as possible.

A statewide network of hotlines and mobile teams answers urgent calls for help, while a "warmline" fields less pressing problems, such as a conflict with a roommate or finding a free meal. Typically, a two-person counseling team will be dispatched to meet callers and defuse the most serious situations. About 60 teams a day are dispatched in Maricopa and Pima counties.

"The system as a whole did what we could to put out the fires," said Suzanne Rabideau, whose Crisis Network contracts with the state to provide telephone and in-person crisis-response in Maricopa and Pima counties. "It's just that people's lives had to deteriorate before we could respond."

The number of calls to mental-health crisis hotlines across Arizona was 26.3 percent higher in May 2011 than in July 2010.

Nelson said the higher call volume and the fact that the vast majority of calls are handled solely over the phone without dispatching a mobile team indicates that the crisis network is meeting the needs of those who lost services. People are reaching out and getting help.

"If you're not able to solve the call on the phone, that would suggest the acuity is much higher," Nelson said.

Magellan Health Services of Arizona, a for-profit state contractor that oversees behavioral-health care for about 70,000 people in Maricopa County, has tracked the rates of incarceration, hospitalization and other key indicators for those with serious mental illness who lost services last July.

Magellan's analysis shows an increase in the incarceration rate and a decrease in psychiatric hospitalization during the first year of cuts.

The rates don't account for the declining numbers of seriously mentally ill people on their rolls.

Magellan Arizona CEO Richard Clarke acknowledged that hundreds of people have dropped out of sight. But among the nearly 6,000 in the county who continue to check in at area clinics and receive mediation, he said, most appear to be managing.

"The system is doing an extremely valiant job of keeping individuals from deteriorating," Clarke said. "We're making the best of a bad situation."

'In really bad shape'

Those who treat the mentally ill say the cuts have hurt people.

They point to growing numbers of people with mental illness showing up in emergency rooms, psychiatric hospitals and jails.

Patients have suffered from adverse reactions to generic drugs and quit taking them or spiraled into paranoia and psychosis when the generic drugs didn't work. Some have resumed abusing alcohol or drugs.

"The most tragic thing for me, as a professional, are the folks who had been previously stable," Caplan said. "The symptoms that had previously been treated emerge. They begin hallucinating. They become paranoid. They become manic."

In the past, Caplan could call a clinic and find a case manager to advise him on the patient's medical history, including medications. Now, he said, for a growing number of patients, there is no one to call.

Dr. Chris Carson, who runs the Valley's only walk-in urgent psychiatric-care center, said the medication switch has caused trouble for patients, who have experienced everything from weight gain and drowsiness to full-blown psychosis.

"I just believe that it was wrong to take a person off a medicine they've been stable on for years and then watch them deteriorate," Carson said.

Business at Carson's Urgent Psychiatric Care Center has increased steadily - growth that mental-health advocates believe is directly tied to the budget cuts. The facility provides emergency crisis stabilization and is one of two urgent psychiatric centers in the Valley.

"We see people who are in a great deal of distress because they lost those services," said Carson, CEO of Connections AZ. "There are not huge numbers of them, but they are in really bad shape."

Data is lacking

Magellan has tracked rates of incarceration, hospitalization and other data for this population during the past year, but it doesn't paint a complete picture. It's unclear what happened to people who have disappeared from the system.

From June 2010 to June 2011, the number of seriously mentally ill people being treated with state funds who are ineligible for Medicaid dropped by 15 percent, or slightly more than 2,000 people, to 11,156.

In Maricopa County, nearly 1,600 fewer people were receiving services, for a 21 percent decrease, according to state data.

They could have moved out of state or completed treatment.

Mental-health advocates fear the declining numbers signal that a growing number of people have pulled away, potentially becoming more of a danger to themselves than to others.

"We have so little information about what's happening to these people. They're like missing in action," said Michael Franczak, a longtime state behavioral-health administrator, now chief operations officer with the Marc Center in Mesa.

Franczak and others who work with the mentally ill say research shows people who don't receive support services, beyond medication, are more likely to suffer from repeat hospitalizations and homelessness or wind up in jail.

"These people did not go away," he said. "They went into higher levels of care in terms of cost."

Maricopa County's Desert Vista Behavioral Health Center, a 125-bed psychiatric hospital in Mesa, has seen the number of people involuntarily admitted for court-ordered evaluations increase by more than 50 percent in the past year. During July, 286 people were admitted to the psychiatric hospital, compared with 188 in July 2010.

Judges order psychiatric evaluations for people deemed a danger to themselves or others, or who are considered "persistently and acutely disabled."

But CEO Gene Cavallo said he doesn't know how much of that growth is from the group that lost benefits.

The number of inmates in the Maricopa County jail system who have received state-funded services for serious mental illness has increased by about 20 percent over the past year, to an estimated 375 people on any given day. The numbers are up this year even as the number of inmates has declined.

Dr. Dawn Noggle, mental-health director for the county's Correctional Health Services, said she can't determine how many of these inmates lost state services. It's possible that her staff, which has grown, may now be better equipped to identify the mentally ill and that could explain the increase.

Mental-health advocates say the full impact of the budget cuts on Arizonans with serious mental illness has yet to be seen.

"What we've been saying is it's going to be a slow train wreck," said Ann Rider, executive director of Recovery Empowerment Network, which include five support centers in metro Phoenix. "People don't deteriorate overnight. They deteriorate over time."